Provider First Line Business Practice Location Address:
178 E QUINN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-237-4223
Provider Business Practice Location Address Fax Number:
208-237-2011
Provider Enumeration Date:
03/23/2007